Innovative Smiles At The Forum, P.C.

Important Notice from

INNOVATIVE SMILES(PHILIP TALLEY DDS)

About

Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice

has information about your current prescription drug coverage with

INNOVATIVE SMILES(PHILIP TALLEY DDS)

and about your options under

Medicare’s prescription drug coverage. This information can help you decide

whether or not you want to join a Medicare drug plan. If you are considering

joining, you should compare your current coverage, including which drugs are

covered at what cost, with the coverage and costs of the plans offering

Medicare prescription drug coverage in your area. Information about where

you can get help to make decisions about your prescription drug coverage is at

the end of this notice.

There are two important things you need to know about your current coverage

and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone

with Medicare. You can get this coverage if you join a Medicare Prescription

Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers

prescription drug coverage. All Medicare drug plans provide at least a

standard level of coverage set by Medicare. Some plans may also offer more

coverage for a higher monthly premium.

INNOVATIVE SMILES(PHILIP TALLEY DDS)

has determined that the

prescription drug coverage offered by the Group Health Plans are, on average

for all plan participants, expected to pay out as much as standard Medicare

prescription drug coverage pays and is therefore considered Creditable

Coverage. Because your existing coverage is Creditable Coverage, you can

keep this coverage and not pay a higher premium (a penalty) if you later

decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and

each year from October 15

through December 7

However, if you lose your current creditable prescription drug coverage, through no

fault of your own, you will also be eligible for a two (2) month Special Enrollment Period

(SEP) to join a Medicare drug plan.